A woman is considered to be menopausal when one year has transpired since her last menstrual period. The HERSH and WHI studies published in 2002 SOUNDED the death Knell for hormone replacement therapy. The damage has been done and manipulation and lies are there: “the risks outweigh the benefits and that is why only irresponsible practitioners prescribe these treatments”. Therefore, the universal panacea for all the evils of the menopause postulated since the 1970S when all menopausal women were told to take estrogen have given way to excommunication and anathema when they are prescribed. The risk of cardiovascular events is low, with an average of seven cases per 10,000. Patients whether or not they use hormone therapy, as is the case with invasive breast cancer, with eight cases more tan average per 10,000 women after five years of use, with the same incidence of in situ breast cancer.
Fortunately, these negative aspects are infrequent and if they are expressed in the form of relative risk they may seem very exasperating. If we say that the risk of having a thromboembolic stroke or cerebrovascular stroke caused by using estrogen in double that present when these are not used, it does not sound the same as saying that there are two cases instead of one per 1, 000 users. We should draw attention to the fact the real risk of having problems is the aging process, as well as other modifiable factors that have a much more detrimental effect such as smoking, alcohol, a sedentary lifestyle, high blood pressure, diabetes and hypercholestrolaemia. Finally, the WHI study did not evaluate the improved quality of life or control of vasomotor symptoms (hot flushes) and genitourinary problems caused by atrophy and dryness which are the main indications for using estrogen, this being the most efficient treatment for obtaining improvements.
Indications for hormone replacement therapy.
The treatment should commence at the start of the menopause, primarily in women with vasomotor or genitourinary symptoms. In principle, this can go on for up to five years, during which the benefits outweigh the risks.
Treatment with low doses of oral or transdermal estradiol associated with natural progesterone or the use of tibolone should be individualized and currently seem safe, now that the baddie no longer seems to be estrogen, rather medroxyprogesterone.
Hormone replacement therapy with individualised closes and schedules, when adequately monitored, can improve the quality of life of most women. Patients with some kind of risk factor, who are the minority, may also benefit from another alternative, nonhormonal treatments, suitable to their individual requirements.
Finally, we refer to the official release from de Spanish Association for the Study of Menopause (AEEM) AND THE Spanish Association for the Study of Menopause ( AEEM), the text of which we include in full because it is totally clear.
AEEM-SEGO release on hormonal therapy.
Hormone replacement therapy during menopause continues to be the most effective treatment form the vasomotor and urogenital symptoms caused by oestrogen deficiency. Hormone replacement therapy is efficient for preventing the bone loss associated with menopause and reduces the incidence of all osteoporotic fractures, including vertebral and hip fracture, even in high risk patients. Hormone replacement therapy has a beneficial effect on the cardiovascular and metabolic system if administered until 60 years of age, in women without the pre-existing disease. Cardiovascular disease is the main cause of disease and death in post-menopausal women. The main preventative actions, as well as balanced diet and not smoking, are weight loss, lowering blood pressure and control of lipids and diabetes.
Delayed commencement of hormone replacement therapy can cause a transitory, slight increase in thromboembolic and cardiovascular events. The risk of thromboembolic events increases with age, and also has a positive association with obesity and thrombophilia. Scientific evidence shows that there is no increase in breast cancer among women who are long-term uses of oestrogen hormone replacement therapy. In combined hormone replacement therapy with medroxyprogesterone, there is a slight risk of breast cancer from the fifth year of use, below 0.1% per annum.
Individualised administration of HRT improves sexuality and quality of life. HRT benefits the connective tissue, skin, joints and intervertebral disc.
The AAEM and SEGO conclude that the risk-benefit ratio of hormone replacement therapy is clearly in favor of the use of these treatments from the early years of menopause until 60 years of age, for symptomatic women. Healthy women in their early postmenopausal period should not worry about the “supposed risk” of hormone replacement therapy. Aspects such as quality of life, mental, emotional, cognitive and sexual health should be taken into consideration when prescribing hormone replacement therapy to our patients.
Dr. Francisco Torres Gallach-Col. Nº 7537- Gynecology Specialist
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